Purpose: Residents' attitudes, practices, and behaviors vary in response to medical error within the context of the culture of their institutions. The purpose of this study was to conduct a systematic review of the literature focused on residents'attitudes and behaviors regarding medical errors in teaching hospitals, including a qualitative review of barriers and proposed countermeasures related to residents' engagement in patient safety. Method: The electronic literature databases of MEDLINE, CINAHL, and ERIC were searched for articles published between January 1988 and June 2008. The search strategy yielded 124 articles. A scoring system was developed to assess the quality of the overall literature. Results: Nineteen studies met eligibility criteria, with 17 published since 2005. There were 12 cross-sectional, 5 qualitative, 1 cohort and 1 pre-post intervention study. Quality assessment scores ranged from 5.5 to 12.5 (possible range 1.0-16.0). Three studies obtained a score of ≤8.0, 5 obtained scores of 8.5 to 10.5, and 11 studies had scores of 11.0 to 12.5. Personal, environmental, and system barriers, and environmental and system countermeasures, were identified. Conclusions: Although the published literature on this topic is limited, those articles that exist identify barriers that make residents reluctant to engage in institutional error identification and/or reduction. Key factors identified included a fear of retribution and the perception of residents as transient care providers. Whereas several countermeasures have been promulgated, the literature reveals scant evidence of their effectiveness. Institutions should recognize and capitalize on the unique experiences of residents and their potential to become owners in patient safety initiatives.